Ultrasound guided procedures in infectious diseases.

To investigate the efficacy and safety assessment of intensive post-operative recovery during thoracoscopic-assisted radical oesophageal carcinoma (OC) treatment. The meta-analysis was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, and English terms were searched in PubMed, Embase, Cochrane Library (2020, Issue 1) and Web of Science, and the same Chinese terms were searched in China National Knowledge Internet and Wanfang Data, with the date range set from January 2010 to January 2020. Search engines, including Google Scholar and Baidu Library, were also applied for manual searches of relevant literature. The final number of articles included was 12, 11 of which were in Chinese and one in English. The basic data of the two groups were statistically analysed. Among 1049 OC patients, 527 were treated with enhanced recovery after surgery (ERAS) and 522 were treated with conventional perioperative management (control group), comparing the operative time, intraoperative blood loss, self-rating anxiety scale (SAS), visual analog scale (VAS), post-operative first venting time, chest tube removal time, post-operative hospitalisation time, post-operative hospitalisation cost, combined complication rate, lung infection rate, anastomotic leak rate and gastric emptying disorder rate. There were statistically significant differences between the ERAS group and the control group in terms of operative day anxiety score, post-operative Visual Analogue Scale, time to first post-operative anal vent, time to chest tube removal, post-operative hospital stay, hospitalisation cost and overall complication rate (weighted mean difference [WMD] = -5.61, 95% confidence interval [CI]: -7.95 to -3.28, P < 0.00001; WMD = -1.58, 95% CI: -1.58, -1.94 to -1.22, P < 0.00001; standardized mean difference [SMD] = -1.86, 95% CI: -2.53 to -1.18, P < 0.00001; SMD = -4.97, 95% CI: -6:73 to -3.21, P < 0.00001; WMD = -3.93, 95% CI: -4.80 to -3.07, P < 0.00001; WMD = -0.65, 95% CI: -0.74~-0.55, P < 0.00001 and relative risk [RR] =0.41, 95% CI: 0.33-0.51, P < 0.00001). ERAS reduced the incidence of pulmonary infection, anastomotic leak and impaired gastric emptying with a statistically significant difference (RR =0.45, 95% CI: 0.31-0.65, P < 0.0001; RR =0.34, 95% CI: 0.16-0.74, P < 0.05; RR =0.34, 95% CI: 0.16-0.73, P < 0.05). ERAS is effective in patients with OC undergoing thoracoscopic-assisted radical OC treatment to improve patients' clinical symptoms and reduce the incidence of adverse effects.

Giant bullae (GB) of the lung are emphysematous air spaces occupying at least one-third of the hemithorax. GB may lead to progressive dyspnoea, compression of adjacent lung and pneumothorax, necessitating surgery as the definitive management in symptomatic patients. We conducted a retrospective analysis of 53 cases of GB operated at a tertiary care centre in India from December 2020 to December 2024. The study cohort included 42 males and 11 females, with a mean age of 49.8 years (range: 12-74). GB occurred unilaterally in 38 patients (right lung - 20, left - 18), bilateral in 15 patients and 6 patients had extensive emphysematous changes also. The primary procedures performed to take care of the bulla included video-assisted thoracic surgery (VATS) bullectomy (30 patients), VATS bullectomy with wedge resection of additional bullae (8 patients) and lobectomy (15 patients). The adjunct procedures performed included talc pleurodesis (24 patients), pleurectomy (13 patients) and decortication in one patient. Median chest drain duration was 6-7 days with an average hospital stay of 6.4 days. Post-operative complications occurred in 12 patients, including prolonged air leak (8), atrial fibrillation (2), ileus (1) and urinary retention (1). No wound infections or deaths were reported, and there were no recurrences of GB during the follow-up period of 48 months. VATS is a safe and effective surgical approach for treating symptomatic GB. It has minimal complications, leads to a quick recovery and has very low chances of recurrence.

The prevalence of pleural, pericardial, or peritoneal effusions among anthrax patients is unknown, as is the impact of drainage on mortality. We identified hospitalized anthrax patients with effusions published 1920-2018 worldwide (n=1,108), excluding cases with insufficient clinical data. Two manuscript authors independently abstracted fluid collection and morbidity data. We evaluated how effusion drainage impacted mortality using logistic regressions. Effusions were present in 99 (13%) of 744 eligible anthrax patients; 65 (66%) of these died. Pleural effusions developed in 72% of patients with inhalation anthrax (N=61), most often bilaterally. Similarly, 55% of ingestion anthrax patients (N=55) developed peritoneal effusions. Pericardial effusions were rare (1.7%). Most pleural Gram-stains or cultures obtained pre-antimicrobials were positive (83%). Of the 44 patients with clinically significant pleural effusions, only 59% received drainage. Drainage of these effusions was associated with survival (OR 38.3, 95% CI: 4.3-339.0), even when controlling for antimicrobials and/or antiserum. Most patients with fatal outcomes following drainage had either bilateral effusions with single-sided drainage or effusion recurrence. Although drainage of clinically significant peritoneal effusions was not associated with survival, laparotomy ±resection for peritonitis was associated (OR 53.6, 95% CI: 9.4-inf). Pleural drainage appears associated with survival. Most inhalation anthrax patients develop bilateral collections, and may require chest-tube insertions. Surgical source control is associated with survival for anthrax-associated peritonitis. Following a wide-area release of Bacillus anthracis, public health authorities should anticipate many patients may require source control (e.g., chest tube drainage or surgery) and plan accordingly.

The complexity of delivering trauma care makes the assessment of its provision challenging. The identification of bellwether procedures has previously been successful in the evaluation of global surgical care; however, any equivalent in assessing trauma care is currently lacking. Through a Delphi process, we aimed to produce the bellwether procedures and processes for global trauma care. A global Delphi process was undertaken with healthcare professionals and academics involved in trauma care from across the world. A list of potential procedures and processes was identified through literature review and expert opinion, along with subsequent additional options suggested by respondents. Three successive rounds were completed, with respondents rating the importance of each procedure or process to be undertaken at any hospital that cares for trauma patients using a five-point Likert scale. A total of 411 respondents from 78 countries completed the initial round of the Delphi process, with minimal attrition observed across rounds. Following three successive rounds of the Delphi and functional aggregation, nine bellwethers of global trauma care were determined, subdivided into three functional categories: 'Resuscitation & Stabilisation'-(1) Advanced Airway Management, (2) Short-term C-spine Immobilisation, (3) Long Bone Immobilisation; 'Diagnosis & Monitoring'-(4) Blood Gas Analysis, (5) Focused Assessment with Sonography in Trauma (FAST) Scanning, (6) Continuous Access to CT Imaging; 'Optimisation & Intervention'-(7) Blood Transfusion, (8) Tube Thoracostomy, (9) Laparotomy and Splenectomy. The Global Trauma Care Delphi study has produced nine metrics that provide pragmatic indicators for the overall assessment of trauma care capabilities at any healthcare setting worldwide. These bellwethers of global trauma care can enable hospitals, local managers and health ministries to identify institutions or regions that may require more in-depth assessment, allowing standards in the management of traumatic injuries to improve.

Acute normovolemic hemodilution (ANH) is an intraoperative blood conservation technique that involves removing a portion of the patient's blood after anesthesia induction and replacing it with fluids to maintain normovolemia. The purpose of this systematic review and meta-analysis was to assess the efficacy and safety of ANH in reducing transfusion requirements and improving hemorrhagic outcomes in adult cardiac surgery patients. Studies were identified through systematic searches of PubMed, Embase, and Cochrane Central databases. Effect estimates were calculated using random-effects models, with heterogeneity assessed using the I2 statistic. Trial sequential analysis (TSA) was employed to evaluate the robustness of cumulative evidence. randomized controlled trials (RCTs) involving 4473 patients were included for further analysis. ANH was associated with a 27% relative reduction in the incidence of allogeneic blood transfusions (RR = 0.73, 95% CI = 0.60 to 0.88; p = 0.0008) and a decrease in the volume of allogeneic red blood cell units transfused (MD = - 0.75 units, 95% CI = - 1.41 to - 0.08; p = 0.020). Fresh frozen plasma transfusion requirements were also significantly reduced (MD = - 0.21 units, 95% CI = - 0.39 to - 0.03; p = 0.0248), along with total blood loss (MD = - 64.35mL, 95% CI = - 114.57 to - 14.13; p = 0.012). However, chest tube drainage, surgical revision, and stroke incidence showed no significant differences between ANH and usual care. This meta-analysis demonstrates that ANH significantly reduces the need for allogeneic blood transfusions and improves outcomes such as red blood cell and fresh frozen plasma usage during cardiac surgery. The findings highlight ANH's potential as an effective blood conservation strategy, though variability in outcomes and heterogeneity warrant further high-quality research to optimize its application in contemporary cardiac surgical practices.

Somatostatin and analogues may reduce chest tube (CT) output in chylothorax caused by post-coronary artery bypass grafting (CABG). However, data is limited to case reports and series. This scoping review aimed to describe the efficacy and safety of somatostatin/analogue use in post-CABG chylothorax. We retrieved from PubMed, Embase, and OVID all studies and case reports describing somatostatin/analogue use in adult patients post-CABG for resolution of chylothorax. The primary outcome was time from somatostatin/analogue initiation to daily CT output <100 mL/day. Chest tube duration, need to repeat invasive intervention, and safety events associated with somatostatin/analogues were also analyzed. Somatostatin/analogues were associated with reductions in CT output, but one-third of patients still required pleurodesis or surgical intervention. No safety events were identified. Patients with lower daily CT outputs at the time of somatostatin/analogue initiation were more likely to avoid repeat intervention than those with higher outputs. In conclusion, somatostatin/analogues appear safe and possibly effective in management of post-CABG chylothorax. Future studies should investigate which patients are most likely to benefit from this therapy.

Not All Black and White: Is Routine Chest Radiography Following Rib Fractures Beneficial?

Artificial intelligence (AI) is increasingly utilized in the medical field, primarily for diagnostic purposes. Although AI has demonstrated efficacy in pneumothorax detection using chest X-rays (CXR), it has yet to be applied for decision-making regarding subsequent treatment. This study aims to develop and evaluate an AI-based system capable of predicting the necessity of chest tube drainage (CTD) in spontaneous pneumothorax patients based on CXR and clinical data. A two-stage AI model was developed: (1) segmentation and quantification of pneumothorax size from CXR using deep learning and (2) prediction of CTD necessity using machine learning models integrating pneumothorax size and patient clinical parameters. The AI model was trained using CXR images and clinical information from 163 pneumothorax patients. Model performance was assessed using area under the receiver operating characteristic curve (AUROC), sensitivity, specificity, and inference time. The AI model demonstrated high segmentation accuracy for pneumothorax (DSC, 76.95%; MAE, 5.06%). In predicting CTD necessity, the AUROC for the AI model incorporating pneumothorax ratio and clinical data was 89.68 (95% CI, 78.57-98.02), outperforming models without pneumothorax ratio (AUROC, 84.13) or with pneumothorax ratio alone (AUROC, 71.03). The sensitivity and specificity of the optimized AI model were 80.95% and 100%, respectively. The mean inference time was 0.75 ± 0.06s, demonstrating potential for real-time clinical application. This study presents an AI-based clinical decision support system capable of accurately predicting the need for CTD in spontaneous pneumothorax patients. By integrating AI-driven pneumothorax quantification and clinical parameters, the model improves decision-making efficiency and accuracy. Future studies with larger datasets and prospective validation are warranted to further refine and validate this approach.

Primary spontaneous pneumothorax (PSP) is a condition that primarily affects young patients and has a high recurrence rate. While surgery is the treatment option associated with the lowest recurrence rate for PSP, some patients experience long-term chest drain placement due to prolonged air leak. Our study aimed to elucidate the relationship between coagulation abnormalities and prolonged postoperative air leak in PSP. Patients who underwent surgery for PSP were retrospectively reviewed. Patients were divided into the exploratory and the validation cohorts. From the exploratory cohort, patients with prolonged chest drain placement were identified as the air-leak prolonged (AL-P) group, and the Control group matched at a 1:4 ratio was selected using propensity score matching. In the exploratory cohort, 15 patients were assigned to the AL-P group and 60 to the control group. Among the coagulation markers including prothrombin time, activated partial thromboplastin time (APTT) and platelet count, univariate analysis revealed a significantly prolonged APTT in the AL-P group (median 33 vs. 31s, odds ratio 1.26, p = 0.006). Multivariate analysis identified prolonged APTT as an independent risk factor for prolonged chest drain placement. Receiver operating characteristic curve of APTT values for predicting the incidence of prolonged chest drain placement showed a cutoff of 31.5s. In the validation cohort, patients with an APTT ≥ 31.5s showed significantly longer chest drain placement (p = 0.03). Our study suggests a potential association between prolonged APTT and prolonged postoperative chest drain placement in patients with PSP.

Intrapleural enzyme therapy (IET) is widely used for pleural infections, including complicated parapneumonic effusions (CPPE) and empyema; however, the role of saline lavage alone or in combination with IET remains uncertain. The SCOPE trial was a two-center, prospective, randomised superiority study designed to determine whether saline lavage alone or combined with IET was superior to IET alone in adults with pleural infection. Patients were randomised in a 1:1:1 ratio to saline lavage alone, saline lavage plus IET (urokinase and DNase), or IET alone. Patients and outcome assessors were blinded to the treatment allocation. The primary endpoint was the duration of pleural drainage. Secondary endpoints included radiographic resolution, need for additional interventions, length of hospital stay, mortality, and adverse events. Eighty-nine patients were analysed (saline, n=30; saline+IET, n=30; IET, n=29). Baseline characteristics were broadly similar across the groups. The median drainage duration was longer with saline lavage alone (4.0 days [IQR 3.0-6.75]) than with IET alone (3.0 days [2.0-4.0], p=0.01) or saline+IET (3.0 days [3.0-3.75], p=0.01). No significant difference was observed between the two IET-containing regimens (p=0.24). Secondary outcomes showed no clear advantage for saline lavage alone or in combination with IET. In pleural infection, saline lavage alone results in a longer drainage duration than IET. In this small superiority trial, adding saline lavage to IET did not demonstrate a clinically meaningful advantage over IET alone.

Simulation-based training is critical for surgical skill acquisition and typically uses soft-preserved body donors, as they represent high-fidelity models (vs. hard-fixed donors) with prolonged periods of preservation (vs. unembalmed donors). While many soft-embalming solutions exist, there remains no standardization between centers nor evaluation of the solution-associated tissue suitability for surgical skills training. The current study aims to remedy that by systematically comparing qualitative ratings (McMaster Embalming Scale [MES]) and quantitative tissue properties (biomechanical testing) of four differentially embalmed tissues (Surgical Reality Fluid, Imperial College London; soft preservation solution, Ethanol-Phenol, and Saturated Salt Solution) captured during analogous clinical and mechanical tests (chest tube insertion and anchoring, bone sawing and electrocautery). MES and mechanical testing results uncovered significant differences across both embalming solutions used and skills performed. Based on these findings and considering cost/safety/accessibility features, ethanol-phenol emerged as an optimal solution for embalming tissues for surgical skills. Still, in comparison to live tissues examined in published studies, embalmed tissues tend to require substantially more force to cut and pierce, which may account for the modest suitability rankings observed across all embalmed tissues. Overall, this suggests that while solution-specific differences exist, their performance is comparable enough to accept any of those tested as adequate models for surgical skills training-an optimistic outcome for laboratories looking to manage both performance and practical concerns during embalming solution selection.

Despite advancements in minimally invasive techniques, lung resection surgery for lung cancer still carries a significant risk of complications. Enhanced recovery after surgery (ERAS) protocols offer strategies to improve outcomes, yet their adoption is still inconsistent. This study aims to develop a series of evidence-based recommendations for ERAS strategies, incorporating insights from thoracic surgeons, anaesthetists, nurses, physiotherapists, and patients. A two-round Delphi consensus process was conducted with experts in the management of thoracic surgery patients. A scientific committee established 62 recommendations across three phases: preoperative (n = 12), intraoperative (n = 30), and postoperative (n = 20). Consensus was defined as ≥ 66% agreement (Likert scale 6-7) or disagreement (Likert 1-2) among panellists. Consensus was reached for 91.7% of preoperative, 86.7% of intraoperative, and 85% of postoperative recommendations. Key recommendations include structured prehabilitation programmes, multimodal analgesia strategies with opioid-sparing approaches, minimally invasive thoracic surgery, early chest drain removal, and pre- and postoperative physiotherapy with early mobilization. This study establishes a structured, consensus-based perioperative management protocol for thoracic surgery patients. By optimizing perioperative care and standardizing interventions, these recommendations aim to improve clinical outcomes, enhance recovery, and raise the quality of care during thoracic surgery. They may also facilitate the broader adoption of ERAS strategies, ultimately improving patient recovery and resource utilization.

Uniportal video-assisted thoracoscopic surgery (uVATS) is an established minimally invasive approach for lung cancer. Uniportal robotic-assisted thoracoscopic surgery (uRATS) is a recent innovation integrating robotic technology with single-incision access. Comparative data between these techniques remain scarce. We retrospectively analyzed patients who underwent anatomic pulmonary resection via uVATS or uRATS at Chang Gung Memorial Hospital between July 2023 and July 2025. Propensity score matching (1:1) was applied using key baseline variables. Perioperative outcomes and cost-effectiveness were assessed. A total of 356 patients (251 uVATS, 105 uRATS) were included; 98 matched pairs were analyzed. Operative time was longer with uRATS (median 179.50 vs. 117.00min, p < 0.001). uRATS was associated with shorter hospital stay (2.70 vs. 3.00 days, p < 0.001), reduced chest drainage duration (1.45vs. 2.00 days, p < 0.001), and lower postoperative day 1 pain scores (p = 0.04). Median N1 and N2 lymph node counts were similar in uRATS and uVATS. Postoperative complication rates did not differ significantly between groups (2.04% vs. 9.18%, p = 0.06). Cost analyses quantified the incremental costs associated with short-term recovery benefits of uRATS. uRATS was associated with modest, short-term differences in selected early postoperative recovery parameters compared with uVATS, accompanied by longer operative time and higher cost. Oncologic surrogate outcomes were comparable between groups, while definitive conclusions regarding long-term oncologic and economic benefits require confirmation in larger, multicenter studies with extended follow-up.

Management of traumatic hemothorax: thresholds for chest tube insertion and outcomes; systematic review

Plasma microbial cell-free DNA (mcfDNA) sequencing is a novel diagnostic tool for pediatric complicated community-acquired pneumonia (cCAP). However, rigorous evaluation of real-world mcfDNA performance is lacking. We compared mcfDNA sequencing to a composite reference standard consisting of blood cultures, pleural fluid (PF) cultures, and targeted PF PCRs in children with cCAP requiring pleural effusion or empyema drainage at Children's Hospital Colorado from 2022 to 2024. We calculated positive/negative percent agreement (PPA/NPA), Jaccard similarity index, and theoretical time to pathogen detection. We investigated mcfDNA positivity in pediatric controls without bacterial infections. Receiver operating characteristic (ROC) analysis explored potential mcfDNA detection cutoff values to define "true clinical positivity." Across 45 cCAP cases, mcfDNA sequencing detected a probable pathogen in 86.7% versus 8.9% by blood culture, 20.0% by PF culture, and 71.1% by PF PCRs (P < 0.001). Against the culture+PCR composite reference standard, mcfDNA had a PPA of 91.9% (83.1%-100.0%), NPA of 35.7% (10.6%-60.8%), and a Jaccard index of 0.74. Bacterial cfDNA was detected in 52% of controls. ROC analysis yielded an area under the curve of 0.9, with potential optimal detection cutoffs ranging between 158 and 491 mcfDNA molecules per microliter. Theoretical median time to pathogen detection was 3.0 days with mcfDNA versus 4.5 days for pleural fluid PCRs, driven primarily by PF sampling time. Plasma mcfDNA sequencing had a significantly higher diagnostic yield than cultures and a similar yield to PF PCRs; however, over half of non-bacterial controls had low-level mcfDNA detected, potentially complicating interpretation. mcfDNA detection level cutoffs may help elucidate the clinical significance of detected pathogens.IMPORTANCEMore sensitive diagnostic tests, particularly non-invasive options, are needed to better identify the causative organism(s) in children with complicated community-acquired pneumonia and help inform pathogen-directed therapy. A novel, potentially powerful diagnostic tool for pneumonia is plasma microbial cell-free DNA sequencing, available commercially as Karius Spectrum. However, unknowns regarding its real-world performance and proper role in clinical practice remain. This study aims to address two ongoing concerns: first, the lack of robust comparisons of microbial cell-free DNA (mcfDNA) sequencing performance against validated conventional and state-of-the-art diagnostic modalities (i.e., pleural fluid testing and blood cultures); and second, the unknown baseline positivity rates of mcfDNA in children without bacterial infections. Results from this study may help inform clinical practice decisions and testing implementation strategies.

ObjectiveSo far, evidence is scarce regarding the impact of rewarming temperature on bleeding after cardiac surgery under cardiopulmonary bypass (CPB). We seek to evaluate how rewarming temperature affects postoperative bleeding in patients undergoing mitral valve repair.MethodsClinical, anesthesia and CPB data were analyzed for 379 adults undergoing isolated mitral regurgitation repair. Platelet levels (1000/μL) were divided into three groups: low, 53-164 (n = 128); medium, 165-208 (n = 126); and high, 209-906 (n = 125). The primary endpoint was chest drainage volume (mL) at 24 postoperative hours. To delineate the degree and impact of rewarming, a variable "rewarming/cooling ratio" was defined as: peak rewarming temperature (°C) divided by nadir cooling temperature (°C). General linear models were used to evaluate factors associated with the volume of 24-h chest drainage.ResultsMean flow rate was 2.7 ± 0.1L/min/m2, nadir core temperature 30.7 ± 1.3°C and peak rewarming temperature 36.2 ± 0.5°C. The "rewarming/cooling ratio" averaged 1.133 ± 0.044.Postoperatively, nadir platelet count was 115 ± 46k/μL, and chest drainage averaged 344 ± 181mL at 24h. Two patients underwent re-exploration for bleeding (0.5%). Transfusion was required in 85 patients (22.4%).Gender (F = 20.585, p < 0.001), platelet count (F = 3.875, p = 0.024), fibrinogen (F = 4.241, p = 0.040), and chest incision (F = 58.097, p < 0.001), rather than the rewarming temperature (F = 2.322, p = 0.128), were factors significantly associated with 24-h chest drainage.A significant interaction existed between platelet levels and "rewarming/cooling ratio" (F = 3.717, p = 0.025), i.e., with a higher "rewarming/cooling ratio", 24-h chest drainage tended to increase in the low platelet group, and to decrease in patients with high and medium platelet levels.ConclusionsIn this series of patients undergoing isolated mitral regurgitation repair, gender, platelet count, fibrin and chest incision, rather than rewarming temperature, were independent factors significantly associated with postoperative bleeding. The impact of rewarming temperature on postoperative bleeding was modified by preoperative platelet levels. It is advisable to avoid excessive cooling during CPB and keep the cooling temperature at maximally allowable level.

Patient: Female, 65-year-oldFinal Diagnosis: Esophagopleural fistulaSymptoms: Drainage of food particles from chest tube fever infectionClinical Procedure: —Specialty: SurgeryObjective: Rare diseaseBackgroundEsophagopleural fistula (EPF) is a rare but life-threatening complication following pneumonectomy, with a reported incidence of up to 1% and a mortality rate ranging from 49% to 63%. Management strategies vary depending on the fistula’s characteristics and the patient’s clinical status, encompassing conservative, endoscopic, and surgical approaches.Case ReportWe report the case of a 65-year-old woman diagnosed with lung adenocarcinoma and N2 nodal involvement who received neoadjuvant chemo-immunotherapy, followed by surgical treatment with left pneumonectomy. In the early postoperative course, she developed fever and pleural contamination with food particles, leading to the diagnosis of EPF via methylene blue test and esophagogastroduodenoscopy (EGD). Initial endoscopic treatment with stent placement was attempted multiple times but its failure prompted the need for surgical intervention. After addressing the infectious and nutritional issues associated with the condition and optimization of the patient’s clinical status, a complex 3-stage procedure was performed involving esophageal exclusion and reconstruction of the gastrointestinal tract using a retrosternally transposed gastric conduit. This was achieved through 3 surgical approaches: laparoscopy, left cervicotomy, and minilaparotomy. The postoperative course was uneventful, with successful reintroduction of oral intake. The esophagogram performed 3 months postoperatively showed a good caliber of the esophagogastric anastomosis and no leakage of contrast from the esophageal lumen.ConclusionsSurgical treatment of large esophagopleural fistulas is indicated when endoscopic treatment fails. Furthermore, esophageal exclusion and bypass is the best course of action when the extent of the fistulous tract presents a problem for direct repair and the chest cavity presents difficulties.

Patient: Male, 77-year-oldFinal DiagnosisAspergillus fumigatus infection • empyema • tuberculosisSymptoms: Cough • feverClinical Procedure: —Specialty: General and Internal MedicineObjective: Unusual clinical courseBackgroundEmpyema is the accumulation of infected fluid within the pleural cavity, sometimes accompanied by pneumothorax. Bacterial empyema is the most common. Tuberculous and fungal empyema are less common and can occur in immunocompromised patients. Empyema caused by mixed infection with both tuberculosis and fungal pathogens is even less common.Case ReportThis report describes a 76-year-old male lung cancer patient admitted to the hospital with fever and cough. He was receiving tislelizumab immunotherapy before admission. Chest CT at admission revealed pneumonia. Following empirical antimicrobial therapy, the pneumonia showed no improvement. He refused bronchoscopy; therefore, a sputum sample was delivered for tNGS testing. Sputum tNGS testing indicated mixed infection with Acinetobacter baumannii, Stenotrophomonas maltophilia, Klebsiella pneumoniae, Streptococcus pneumoniae, Aspergillus fumigatus, Aspergillus flavus, and COVID-19. Following adjustment of the antimicrobial regimen based on pathogenetic findings, he developed empyema complicated by pneumothorax. A chest tube was inserted, resulting in improvement of empyema and pneumothorax symptoms. Bacterial, fungal, and Mycobacterium tuberculosis cultures of the pleural effusion were all negative. Further tNGS analysis of the pleural effusion revealed a mixed infection with Mycobacterium tuberculosis and Aspergillus fumigatus. The patient refused further treatment and died 5 days after discharge.ConclusionsDiagnosis of tuberculous empyema and fungal empyema is challenging and the prognosis is poor. In patients with malignant tumors, particularly those receiving immunotherapy, the possibility of Mycobacterium tuberculosis infection and fungal infections should be fully considered when infections occur, and early diagnosis and treatment are essential.

Gonorrhoea is an infection caused by Neisseria gonorrhoeae. It is considered a significant public health problem. Asymptomatic infections are common, especially in women, and can lead to systemic dissemination. We discuss a unique case of a 48-year old woman presenting with disseminated gonococcal infection (DGI) complicated by pleural and pericardial effusions. Microbiological confirmation was obtained by N. gonorrhoeae polymerase chain reaction on pleural fluid. The patient was successfully treated with intravenous ceftriaxone and pleural drainage. We provide a comprehensive review of the literature on gonococcal pleuritis and pericarditis. Both are rare complications of (DGI), but the combination has never been described in literature. This case highlights the importance of early recognition and treatment of gonorrhoea and DGI to prevent severe complications. Not applicable.